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With sincere regards
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On May 11,2011




Dr. Shankar P.R.

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Important Notice

Original article / research
Year : 2009 | Month : December | Volume : 3 | Issue : 6 | Page : 1841 - 1846 Full Version

Cerebrospinal Fluid And Serum Zinc, Copper, Magnesium And Calcium Levels In Children With Idiopathic Seizure


Published: December 1, 2009 | DOI: https://doi.org/10.7860/JCDR/2009/.586
PRASAD R *, SINGH A *, DAS B K *, UPADHYAY R S **,SINGH T B ***, MISHRA O P *

*Dept. of Pediatrics, Institute of Medical Sciences, **Dept. of Botany, ***Dept. of Biostatistics, Banaras Hindu University, Varanasi. India.

Correspondence Address :
Dr. Rajniti Prasad,Sr Lecturer,Department of Pediatrics,Institute of Medical Sciences,Banaras Hindu University,
Varanasi – 221005. (India).e
mail:rajnitip@yahoo.co.in

Abstract

Objectives: The present study was conducted to observe the alteration and their relations in cerebrospinal fluid (CSF) and serum Zinc (Zn), Copper (Cu), Magnesium (Mg) and calcium (Ca) levels in patients with different type of idiopathic seizure and to determine the ratios of serum and CSF Ca/Mg and Cu/Zn.
Methods: The children of aged 1 to 14 years, having two or more unprovoked seizures with normal MRI scan and abnormal EEG were included in study group. Control group consisted of 40 healthy children without seizure. Zn, Mg and Cu levels in CSF and serum were analyzed by atomic absorption spectrophotometer.
Results: The study subjects included 34 generalized seizures (GS), 5 cases of simple partial seizure (SPS) and 5 Complex partial seizures (CPS). Serum copper (Cu) was significantly elevated (P-0.01) in children with seizure. Within seizure group, serum Mg was significantly increased in GS and serum copper (Cu) levels were significantly increased in CPS and GS as compared to control (p-0.001). However, calcium and zinc did not show any significant change in all groups. CSF Calcium was significantly increased in CPS patients. The ratio obtained for the levels of these parameters revealed a significant increase in serum Cu/Zn ratio (P-0.002) and CSF Ca/Mg (P-0.04) in patients with idiopathic seizure as compared to control. This ratio was also significant between SPS versus CPS and CPS versus GS.
Conclusion: The findings of present study suggest that high serum Cu and increased ratio of serum Cu/Zn and CSF Ca/ Mg may be responsible for enhanced neuronal excitability in children with idiopathic seizures.

Keywords

Idiopathic seizure, zinc, copper, magnesium , calcium

Introduction
The exact pathogenesis of seizure is not fully understood but involves several factors like genetic predisposition, changes in the levels of neurotransmitters and some trace elements. Several reports suggested that the level of some trace elements play a vital role in causation of seizure (1), (2). Among trace elements, Zinc (Zn) acts as a co-factor of glutamic acid decarboxylase, an enzyme which maintains the production of GABA in central nervous system and decreased level of Zn in CSF has also been observed in Febrile seizure (2), (3). Magnesium (Mg) is also involved in neuronal function and inhibits the facilitatory effects of calcium on synaptic transmission and exerts a voltage dependent blockage of N-methyl-D-aspartate (NMDA) receptor channel. Copper (Cu) inhibits Mg++-adenosine triphosphatase(ATPase) and Na+-K+-ATPase enzymes and disturbs the sodium and potassium homeostasis, which results in genesis of epileptiform discharges (4). In some cases the altered levels of trace elements in epileptic patients were attributed to anti-convulsant drugs therapy or due to other unknown reasons.

A careful literature review reveals that a comprehensive record of zinc, copper, magnesium and calcium in serum and CSF and their ratios in children with idiopathic seizures is missing. Hence to observe their significance in children, the current study was conducted to estimate their levels in children suffering from idiopathic seizures. Furthermore, an attempt has been made to find out ratios of them such as Ca/Mg, Cu/Zn and to correlate with types of seizure.

Material and Methods

The present study was carried out in Department of Pediatrics, a tertiary care hospital, India from June 2006 to July 2008. A total of 44 children suffering from seizure aged, 1 year to 14 years were enrolled for the study.

Inclusion Criteria
Cases: Children of age group 1 year to 14 years, having two or more unprovoked seizures (first presentations in hospitals) with normal CT / MRI Scan and abnormal encephalogram(EEG) were included in study group. Children with GS were treated with sodium and valproic acid, whereas cases with SPS and CPS received carbamazepine and valproic acid respectively.

Control
40 healthy children (22 male and 18 female) without seizures.

Exclusion criteria
Children with malnutrition, acute bacterial meningitis and those taking Cu, Zn, Mg and Ca containing preparations were excluded from the study.

The protocol of study was approved by Institute Postgraduate Medical Board. Parents of each patient were explained about the illness of their child and informed consent was taken from the parent or legal guardian after explaining the procedure, which is an integral part of study.

Collection And Storage Of Samples
Blood samples were collected through vein puncture using aseptic precautions. The serum was separated and transferred into plastic tubes. The patients underwent lumbar puncture and the CSF was collected in acid washed plastic tubes. One millimeter of CSF was used for trace elements estimation. Both CSF and serum samples were stored at -20C until analysis. The glass and polypropylene equipments used for trace elements analysis were soaked in 10% (v/v) nitric acid for 12 hours and then rinsed with double distilled deionized water.

Estimation of Cu, Zn, Ca and Mg
The Cu, Zn, Ca and Mg levels in CSF and serum were assayed by atomic absorption spectrophotometer in the Department of Botany, Faculty of Science, Banaras Hindu University, Varanasi. Both CSF and serum samples were diluted with double deionized distilled water and dilution factor was 1:3 and 1:6 for zinc and copper respectively and 1:10 for Ca, Mg estimation. The standard solution contained 100 g/ml of each element and used for calculation in analysis of Cu, Zn, Ca and Mg levels in CSF and serum. Sample reading was taken thrice and arithmetic mean was calculated.

Statistical Analysis
The data was analyzed using SPSS software version 10. Student‘t’ test and Man Whitney U-test was used to compare the significant difference of means between control and patients. Data, which did not follow normal Gaussian distribution ,were compared by Wilcoxan Rank sum or Kruskal- Wallis test. Post-hock test has been used to find out pair wise significant difference, if one way ANOVA is significant. The ratio and correlation coefficients were also calculated. Categorical data were compared by calculating the chi-square value or by Fischer exact test.

Discussion

Serum copper levels in children with seizure and their subgroups were significantly increased as observed by other workers (5), (6), (7), (8), (9) but Smith et al.(10) and Kurekci et al.(11) have reported no significant change. The increased copper levels in serum may be due to effect of anti-epileptic drugs, increased hepatic synthesis or decreased breakdown or both of copper binding protein, altered intestinal absorption and altered excretion patterns, changes in the distribution among body tissues or some combination of above factors (8), (9). CSF Cu were found comparable in both cases and control as observed by Goody et al.(12) This variation in serum and CSF value might be due to some unknown factors which need to be further evaluated.

Zinc is essential for normal development of the brain. Although serum and CSF Zn level in patients with seizure was found to be decreased but statistically insignificant as observed by other workers (9), (10), (12). Low Zn concentrations have been reported in serum and CSF of patients with epilepsy (13). The mechanism by which depletion of zinc facilitates seizure activity is hypothesized as its inhibitory effect on GABA, an inhibitory neuro-transmitter. Zinc also plays an important role in both the synthesis and function of GABA (14). Goody et al;(12) and Kapaki et al;(15) had reported increased CSF concentration in patients with neurological disorders.

The present study demonstrated low serum and CSF Mg levels in cases but insignificant. Our results are simillar with study of other workers (16), (17), (18), (19). However Alwarez-Dominiguez et al. (20) showed higher serum magnesium level in epilepsy. Rude (21) hypothesized that magnesium deficiency is responsible for hyper- excitability of neuron. It is apparent from the study that in normal subjects the serum magnesium levels is lower than levels in CSF, suggesting that some mechanism other than mere diffusion is responsible for maintaining this relatively higher concentration in CSF.

It is well documented that low levels of calcium are responsible for initiation of seizures. However, in present study serum calcium in seizure remained comparable to the control as reported by Rutter et al (22) but other workers (18), (19) showed higher levels of calcium in epileptic children. Calcium facilitates the release of acetylcholine by nerve impulses, which may be responsible for neuromuscular irritability. Hypomagnesemia and hypercalcemia combine to produce a membrane state, which becomes responsive to an otherwise sub-threshold stimulus.

Generalized seizure group had significantly higher levels of serum Mg as compared to partial seizure group in present study. Shah et al (16) had found nearly comparable levels unlike our result. The present study also showed significant decrease in CSF Ca in children with SPS and CPS. We can hypothesize that type of seizure had influence on concentration of Mg and Cu in serum.

It was observed that serum Cu/Zn and CSF Ca/Mg ratios were significantly elevated in study group. The elevated Cu/Zn ratio may be closely associated with initiation and continuance of seizures. Leaver et al.(23) also observed decline both in calcium and magnesium concentrations and high serum Ca/Mg ratio as with our result. Our observation on the possible use of Cu/Zn ratio is a new concept and may help to judge enhancement of neuronal excitability.
The strongest correlations observed in our study were between CSF Ca and CSF Mg (r=0.39) as observed by Woodbury et al.(24) and Bogden JD et al. (25) The correlation between plasma and CSF Mg (r=0.35) although significant, is not strong enough to allow a useful estimate of Mg concentration in CSF from its concentration in plasma.
The estimation of serum and CSF levels of Ca, Mg, Cu and Zn and their ratios are essential for the rational understanding of pathogenesis and management of childhood idiopathic seizure and their sub-groups. The changes in trace metals might be associated to type of seizure rather than anti-convulsant therapy. However, it is suggested to conduct a study with greater sample size to evaluate the role of trace elements and their ratios in childhood seizures.

References

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Mishra OP, Singhal D, Upadhya RS, Prasad R, Atri D. Cerebrospinal fluid zinc, magnesium, copper and gamma-aminobutyric acid levels in febrile seizure. J Pediatr Neurol 2007; 5:39-44.
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Mollah MA, Dey SA, Tarafdar SA et al. Zinc in CSF of patients with Febrile convulsion. Indian J Pediatr 2002;69: 859-61.
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Donalson J, St Pierre T, Minnich J, Barbeau A. Seizures in rats associated with divalent cation inhibition of Na+- K+-ATP’ase. Can J Biochem 1971;49: 1217-24.
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Canelas HM, Assis LM, De Jorge FB, Tolosa APM, Cintra ABU. Disorders of copper metabolism in epilepsy. Acta Neurol Scand 1964; 40: 97-106.
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Plum CM, Hansen SE. Studies on variations in serum copper and serum copper oxidase activity, together with studies on the copper content of the cerebrospinal fluid, with particular reference to the variations in multiple sclerosis. Acta Psychiatr Neurol Scand 1960;148: 41-78.
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Armutcu F, Ozerol E, Gurel A, Kanter M, Vural H, Yakini C, Akyol O. Effect of long-term therapy with sodium valproate on nail and serum trace element status in epileptic children. Biol. Trace Elem Res 2004;102:1-10.
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Kuzuya T, Hasegawa T, Shimizu K, Nabeshima T. Effect of anti-epileptic drugs on serum zinc and copper concentrations in epileptic patients. Int J Clin Pharmacol Ther Toxicol 1993;31: 61-65.
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Smith WG, Bone I. Copper, zinc and magnesium levels in epilepsy, J Neurol Neurosurg Psychiatr. 1982;45:1072.
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Kurekci AE, Alpay F, Tanindi S, Gokcay E, Ozean O, Akin R, Isimer A, Sayal A. Plasma trace element, plasma glutathione peroxidase and superoxide dismutase levels in Epileptic children seizures receiving antiepileptic drug therapy. Epilepsia 1995;36: 600-4.
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Gooddy W, TR Williams, Nicholas D. Spark–source mass spectrometry in the investigation of neurological disease:Multi element analysis in blood and cerebrospinal fluid. Brain 1974;97: 327.
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Barbeau A, Donaldson J. Zinc, Taurine and Epilepsy. Arch Neurol 1974;30:52-58.
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Chvapil M. New aspects in the biological role of zinc: A Stabilizer of macro-molecules and biological membranes. Life Sci 1973;13: 1041-49.
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Kapaki E, Segdistsa J, Papageorgiou C. Zinc copper and magnesium concentration in serum and CSF of patients with neurological disorders. Acta Neurol Scand 1989;79: 373-78.
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Shah QA, Jamil AA, Gupta VP, Kabiraj MM, Shah AH. Changes in Serum Electrolytes in Childhood Epilepsy: A Hospital Based Prospective. Greenwich J Sci Tech 2001;2: 18-27.
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Meret S, Henkin RI. Simultaneous direct estimation by Atomic Absorption Spectrophotometry of copper and zinc in serum, urine and cerebrospinal fluid. Clin Chem 1971;17: 369-73.
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Govil MK, Mangal BD, Alam SM, Mahendru RK, Srivastava DK, Mudgal JC. Serum and cerebrospinal fluid calcium and magnesium levels in cases of idiopathic grand mal epilepsy and induced convulsions. J Assoc Phys India 1981; 29: 695-99.
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Sood AK, Handa R, Malhotra RC, Gupta BS. Serum, CSF, RBC, Urinary Levels of Magnesium and Calcium in Idiopathic generalized tonic clonic Seizures. Indian J Med Res 1993; 98:152-59.
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Alvarez Dominquez L, Prats-Quinzannos J, Calvetmieas E, Alsina- Kirtchner MJ , Ramon Bariza F. Study of calcium and magnesium in cerebrospinal fluid and its relation to different neurological diseases. Ann Esp Pediatr1978; 11: 753-62.
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Rude RK. Magnesium Metabolism and Deficiency. Endocrinol Metabl Clin North America1993; 22: 377-95.
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Rutter N, Smales OR. Calcium, Magnesium and Glucose levels in Blood and CSF of children with Febrile Convulsions. Arch Dis Child 1976;5: 141-3.
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Leaver DD, Parkinson GB, Schneider KM. Neurological consequences of Magnesium Deficiency: Correlations with Epilepsy. Clin Exp Pharmacol Physiol 1987; 14: 361-70.
24.
Woodbury J, Lyons K, Carretta R, Hahn A, Sullivan JF. Cerebrospinal fluid and serum levels of magnesium, zinc and calcium in man. Neurology 1968;18:700-5.

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com